Laws put in place to protect consumers from high costs associated with freestanding emergency rooms may not be working as intended. Dr. Vivian Ho, a health economist at Rice University's Baker Institute, Dr. Paul Hain, BCBSTX North Texas Market President, and co-host Ross Blackstone, BCBSTX Director of Strategic Influence, join Dr. McCoy to discuss how you can protect yourself. You can listen to the complete discussion in podcast form on Apple Podcasts and SoundCloud.

Additional links in the Emergency Care Series:

Blue Promise: Emergency Care Part 1: Our data shows emergency room costs have gone up by 182 percent in the last four years in Texas. What is going on in the market and what can we do to slow runaway health care costs?

Blue Promise is an online video blog that aims to address complicated health issues with candid conversations from subject matter experts. New editions are published regularly and are hosted by Dr. Dan McCoy, President of Blue Cross and Blue Shield of Texas.

DAN: The Texas legislature was successful in passing laws to protect healthcare consumers from

the cost and confusion associated with freestanding emergency rooms, but are the laws working as intended? And what still needs to be done? Thanks for joining us for this edition of Blue Promise. I'm Dr. Dan McCoy. I'm the President of Blue Cross and Blue Shield of Texas and I'm here with my cohost Ross Blackstone.

ROSS: We've talked a little bit about the number of segments about the problems related to freestanding ERs… kind of level set for us. What was the landscape like? What were the problems or the issues before the 2017 session?

PAUL: Well you know the issues were myriad and varied but the ones that they were really trying to solve was misrepresentation by the freestanding ERs about whether they were in or not in network with commercial insurance plans. And what you would find is that you see signs saying we accept all insurance even when they were out of network and really…

DAN: So Paul, I actually saw a grocery bag that had freestanding ER name on one side and it said we accept Blue Cross and five of my competitors…

PAUL: Yep

DAN: And then on the back it said, ‘We do not accept Medicare, Medicaid or Tricare.’

PAUL: Right. You know that's really what these laws were aiming at because first off very few freestanding ERs except commercial insurance. But what they're really saying is that they'll accept the out of network payment and then reserve the right to send an enormous bill to the consumer who walks into the place.

DAN: So let's talk about that for a minute because I think it's a really important concept…

modern insurance covers emergency.

PAUL: That's correct.

DAN: So the fact.. an emergency room if you walked in there you would be covered.

PAUL: Right.

DAN: That's true, right?

PAUL: Right.

DAN: But you might have an out of network benefit, right?

PAUL: Exactly and really the problem, of course, is that when you go into an out of network ER like that they can.. there's no regulation about what they can charge so they can literally make up any charge they want and say you owe them that money then from the commercial insurer

will come a reasonable rate of payment and the gap between the reasonable rate of payment and whatever it is they made up their charges is what then they're allowed to bill the patient. That could be a responsibility of the consumer, absolutely.

ROSS: So Dr. Ho what happened in the 2017 session?

VIVIAN: Well there were a couple of important pieces of legislation that passed. First there was Senate Bill 507 by Senator Hancock and that expanded the mediation process to those who have PPO insurance plans so that they could if they feel that they have a bill that is unfair and unjustified that they can go to the Texas Department of Insurance and get mediation.

DAN: And that was really a powerful piece of legislation because that meant for the first time people had the opportunity to have some if you will mediation, arbitration, whatever you

want to call it, but they had the ability to have a discussion about the bill

VIVIAN: Absolutely… So there is somewhere to go to represent the consumer and protect them

in any unfortunate cases when things are popping up because of the freestanding ERs. The other is House Bill 3276 by Representative Oliverson and it requires that the freestanding ERs disclosed to the patient coming in whether or not their insurance includes that facility as an

in-network provider

ROSS: And then there were three others that we won't get into the details of every one but Dr. Hain were they successful?

PAUL: Well you know success is hard to define but I'll certainly say in this case it seems like there's an awful lot of out of network freestanding ERs not following these laws. The Dallas Morning News had a nice piece on it and I know they called a bunch of freestanding ERs and

just basically asked the question, ‘Do you take such and such insurance?’ And even knowing ahead of time that these freestanding ERs did not, the answer was more often than not

was, ‘yes we take all insurance.’ And if you go on their website you'll often see declarations that they take all insurance posted right next to the required posting from HB 3276 saying that there may be a facility fee and this is an E.R. and we don't take any insurance but the bigger banner is we accept all insurance, so they're complying sometimes with the letter of the law but absolutely not with the spirit and sometimes really with neither.

ROSS: Ok so we're making some progress… We have another legislative session coming up next year. I'll ask all of you really what should we be looking and what should we be doing to make it better?

VIVIAN: Well, my understanding is that Senator Schwertner, Senator Taylor, Senator Hancock are all introducing some types of legislation and the things that they are aiming to do, it's everything ranging from increasing administrative penalties to freestanding ERs that are not following the legislation that's just been introduced. There is others requiring specific disclosure notice provisions by freestanding ERs again about which networks they're in. And there's an effort just in general to hold the bad actors accountable for their market behavior. So well you know I think that's what we'd like to push for. I would like also like to see some effort at real price transparency, actually requiring these providers to post the prices that they will be charged for every common services just so the patient knows what they're going to be in for if they go ahead and seek care at that facility.

PAUL: I couldn't agree more. You know and you hear a lot, ‘well we don't know what's going to cost the patient before we see the patient.’ But if you're a freestanding ER and you do a medical screening exam to decide if somebody has an emergency condition or not and they don't have an emergency condition, I would think you then have enough time to tell them how much it's going to cost to swab their throat for their strep throat. I'd love to see some kind of price transparency happen that way.

DAN: I guess if you asked me I would tell you that in times of a hurricane, if somebody overcharges you for gasoline, then the state can intervene for price gouging. It just makes sense to me that if it's a true medical emergency, you shouldn't have to debate economics. No offense, Dr. Ho, I know you're an economist, but you shouldn't have to debate economics about

what that cost is going to be. So I hope there are some measures introduced that allow the state to intervene in price gouging in times of an emergency I think that's what consumers and really patients need to protect them.

ROSS: So I'll just… last question. For the average Joe, for the average patient, the average member, Dr. Hain what do people need to know to protect themselves?

PAUL: Well I think you really need to know the vast majority of freestanding ERs aren't in network and you need to know to walk in through make sure that you can ask the question or look up on our apps. Is this an urgent care? Is this an E.R.? And if you're there for an urgent care visit and you've wandered into the ER, you need to understand what the financial consequences are going to be to your pocketbook.

ROSS: All right.

DAN: And I think the only thing I might add to that is find a relationship with a primary

care physician.

PAUL: Boy that’s a good point.

DAN: Because you're having a relationship with a primary care physician can solve

so many of your problems related to these kinds of services

PAUL: Absolutely.

DAN: So thank you both for being here. Dr. Ho, thanks for visiting us here in studio today and Ross and Dr. Hain, and thanks for joining us for this edition of Blue Promise.

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